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Application for Lump-Sum Payment |
PBGC Form 720MP Approved OMB 1212-0055 Expires
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Pension
Benefit Guaranty Corporation. |
For assistance, call 1-800-400-7242 |
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Plan Name: FX.PrismCase.CaseTitle.XF |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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Date
Printed: |
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Date of Plan Termination: FX.PrismCase.DOPT.XF |
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INSTRUCTIONS: Use this form to request a lump-sum payment. As proof of your date of birth, enclose a copy of your birth or baptism certificate, or U.S. Passport. If you are a deceased participant’s spouse, enclose a copy of your marriage certificate if you have not already sent it to us. Please make sure that proof documents are legible before sending to PBGC. If you have questions about other documents we accept as proof, call our Customer Contact Center at 1-800-400-7242. Print clearly with blue or black ink.
1. General information about you
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Social Security Number |
Date of Birth (Copy of Proof Required) |
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male |
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If you are the participant and worked after the date the plan terminated, what year did you stop working for the employer who sponsored your pension plan? |
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CONTINUE |
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Application for Lump-Sum Payment Form 720MP, page 2 of 3 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name: FX.PrismCust.FullName.XF |
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2. Payment Election – Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments. Be sure you understand the tax implications of having PBGC pay the lump sum directly to you or to an individual retirement arrangement (IRA) or a qualified retirement plan.
Please elect only one option - A or B or C. If you do not elect an option or if you elect more than one option, PBGC will pay you according to option B.
A. Roll over my payment to an IRA or a plan – Send my entire payment, plus interest, directly to an IRA or a qualified retirement plan. I understand that PBGC will not withhold taxes from my payment. |
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B. Pay me directly – Send the entire payment, plus interest, directly to me. I understand that PBGC will withhold 20% of the taxable amount of my payment for federal income tax.
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C. Split my payment - Send some of the money, plus interest, directly to me, and send some directly to an IRA or a qualified retirement plan, as follows: |
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1. Send this much directly to me:
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I understand that PBGC will withhold 20% of the taxable amount for federal income tax.
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2. Send this much to an IRA or a qualified retirement plan.
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I understand that PBGC will not withhold taxes from this part of my payment. Note: the amount must be at least $500.
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If you elected option A or C, complete Section D on page 3.
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CONTINUE |
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Application for Lump-Sum Payment Form 720MP, page 3 of 3 |
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Plan Number: FX.PrismCase.CaseIdNmbr.XF |
Participant Name : FX.PrismCust.FullName.XF |
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Payment Election (Continued)
D. Rollover Information |
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Name of IRA or Plan: |
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Type of IRA or Plan:
Traditional IRA Roth IRA
Qualified retirement plan
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Account Number |
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Name of the Institution / Trustee |
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Mailing Address
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3. Signature – Sign and date this application in the presence of a Notary Public. Knowingly and willfully making false, fictitious or fraudulent statements to the Pension Benefit Guaranty Corporation is a crime punishable under Title 18, Section 1001, United States Code.
I declare under penalty of perjury that all of the information I have provided on this form is true and correct.
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SIGNATURE
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DATE |
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To be completed by Notary Public witnessing your signature above: |
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Subscribed and sworn to before me this __________________ day of ____________________, Year______ |
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Date My Commission Expires |
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Payee Information Form_PBGC Form XXX |
Author | PBGC\IOD |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |